P - 39382Building ���;�1�l�.N��L�� Permit No.: ` _
Insp�ctions �����1�'�'�.� �g.�'�'�,��1�.���1`� Rec�e�yed B� �� ,
763-572-36U4 ���'� ��+ �'����+ � Date�Z��d: � , f
76J-J�2-4'977 FAx EFFECTIVE7-i-2010
DATE p� %�` 1 1 YOUR E-MAIL ADDRESS
SITE ADDRESS �l �� C � A � h ^w-t,.,.� n �-�''t � � �
TH1S APPLICANT IS: ❑ OWNEP. �ONTRACTOR
PROPERT'Y NAME: �TI r-� J� v A c� � h _ _ _
. OWNER/ ADDRESS: t�i' 1 � A�h 'J-w,9 c_ L n� t� ,� CITY K�i, , �C11 +. STAT� N� ZIP J�� V.� Y,
TENANT PHONE: '7 C�.S , S-7y — U�`� t�
CONTRACTOR COMPANY NAME: �,, � �, i ,� �e (C- SJ° � L � E-- � � � �- ( —
SUBMIT A COPY OF CONTACT PERSON: C�.,✓ t a �r-F� F
YOUR STATE STATE LICENSE # EXP DATE
LICENSE WITH ADDRESS: ��`t G {'�j ��-�.J, S� , NQ CITY F�-' ►,c� l� STATE�i"yZIP � r� �J�1.-
�PPLICATION pHONE "7 E'� � 1 J if a 1�i S FAX
PERMTT TYPE �INGLE FAMILY ❑ TWO FAMILY ❑ TOWNHOUSE
T'YPE OF WORK: � NEW �REPLACEMENT ❑ ALTERATION/REMODEL
DETAILED DESCRIPTION OF WORK Z.✓► %�'� �� � i/� I F-c �.� t��" F� �: �+ �"� ���
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. F'IXTURES: (INDIGATE TOTAL NUMBER OF EACH BELOV�
PROVIDE HEAT LO5S CALC'S PER MANUAL J 2006 ASffiiAE HANDBOOK
Equipment Installed £"CL� MFG: IZ.. v A MODEL: � V�' '� V°� n A F S SIZEBTU �o S�� cl 0 c R�' t�
� C MFG: I�Z v�� MODEL; U� (Q�.. '� �� JA'� � ��U ►'�
MFG: MODEL: SIZEBTU
� A/C $25.00 _FIItEPLACE (GAS) $I5.00 GAS RANGE/OVEN $10.00
AIR TO AIR EXCHANGEER $15 _FIIZEPLACE (WOOD) $35.00 NEW GAS GRILL $] 0.00
�BOILER $35.00 �FURNACE $35.00 GAS UNIT HTR $10.00
^CHIMNEY LINER $10.00 _GAS DRYER $10.00 POOL HEATER $35.00
DUCT WORK $10.00 GAS PIPING $10.00 VENTILATOR $15.00
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THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit and work is not to start without a permit; that the wark will be in accordance with the
approved plan in the case of all work which requires review and approval of plans.
SIGNATURE OF APPLICANT �� �'�'"� `� ; F�_' _P�NT I*IAME � � �� `� � � DATE �� � � � %
APPROVAL INSPECTORS SIGNATURE DATE
' PLEASE NO'T'E_ SEl?ARAT,E I'� TT RE REQUIk�D.FOR: eUILDTI�IG; E�EGTR.iCAL IvI�CI�NICA-L `VJ.t)FtK:
City of �ridley
uildin� Inspe�#ions Department
6431 University Avenue NE, Fridley, MN 5�4�2
763-572-3604 FAX: 763-502-4977
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